Surgery Scheduling Forms

Thank you for your interest in our surgery scheduling forms. It is our goal at Wesley to make the surgery scheduling process as easy for you as possible.

We have created a form which contains all the information needed to schedule your patients for surgery without receiving multiple calls from different departments for additional information. The form is in PDF format. You can type the information on the form, print it out, and fax it along with a copy of the patient's insurance card and personal identification. Histories and physicals or any additional forms can be included.

We have eliminated the need to fax to multiple locations. Please fax only to (316) 962-7827.

Some offices already have their own forms. Those will be fine to use, as long as all the necessary information is included on the form, and the Surgeon has signed the orders. Sometimes handwriting is difficult to read, especially after the form has been sent through the fax, so please keep this in mind. Please include the patient's name on the top of each page you send.

Admit Status Order

Adult Surgical PreOp Antibiotic Prophylaxis

Medicare Order Form – 2 Midnight Rule

MR1101 (N04 12) Surgeon Attestation Patient Suitability for Total Joint Replacement 5h

Operating Room Case Scheduling Form

These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:
Get Acrobat Reader (this link opens a new browser tab or window).